Chief Complaint

... he said the pain was constant and slowly dulled away on his trip to the E.R. He reported that his pain was exactly like the pain he had experienced when he was diagnosed with a pneumothorax. He denied radiation of pain, palpitations, head ache, dizziness, and wheezing. Recent and Present Medications: none Past Medical History: In 2003 the patient broke his right ankle playing basketball. August 12th, 2004, the patient was diagnosed with a 15% pneumothorax after experiencing chest pain while weight lifting. Family Medical History: none Physical Examination: Age 16 Height 6’2” Weight 144 BP 125/84 Pulse 88 Respirations 18 SpO2 99% room air The patient appeared to be in no immediate distress. Skin: no erythema, cyanosis, or edema. Lymph Nodes: none palpable Head: normocephalic, atraumatic Ears: finger rub heard, non tender. Eyes and Fundi: Equal and reactive to light. Extra=ocular movements intact. Nose: septum undeviated Mouth, Teeth and Throat: moist mucous membranes, no erythema Chest: symmetrical Lungs: no ...

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Words: 317
Pages: 1.3
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